Plastics

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=====How to Rock Plastic Surgery - Intern Guide=====

====INTERN PEARLS====
{{ :medical_student:intern_pearls_1_.docx |}}

====General Daily Flow====
  * Prepare patient lists with pertinent vital signs, lab values, I's & O's, and imaging/culture results.
  * Sign-out starts anytime before 6AM and occurs on the 6th floor of AIP2 tower in the surgical resident workroom between the second and third nursing station. You are responsible for grabbing the plastic surgery floor pager. There may be instances where the hand team will ask that you grab the hand pager for them and place it in the plastic surgery call room. The hand team will inform you if that is the case
  * Complete orders, consults, and notes after rounding. Update the senior resident with any pertinent news, updates, results throughout the day.
  * Usually you will be assigned to one or more surgical cases. If you have a first-start case (i.e. 7:30 start), ordering all pre-operative orders and consenting the patient is the priority before floor work
  * If you are not assigned to any cases and have finished your floor work, you are encouraged to join ongoing cases
  * Plastic surgery consults will go through the plastic surgery pager. See the patient and staff the patient with the mid-level resident. If the mid-level resident is unavailable, staff the consult with the senior/chief resident
  * After all cases are completed, ensure a post op check is performed on patients being admitted to the hospital - this can be signed out to the night intern if the case finishes later in the afternoon
  * Sign-out the pager to the night intern at 6PM on AIP2 6th floor


====Detailed Daily Flow====

===Before rounds===
  * Print patient list: Go to plastics patient list,
  * Include Room, Name, Age, Attending, Handoff To do, Blank column for columns\\  
  * Get vitals: temp, HR, BP, RR, sats, oxygen requirement\\
  * I/Os: total in (24hrs) - In: PO/G tube in, Out: UOP, NG tubes, drains, wound vac, ostomy - for drains have current and previous day outputs
  * Record ecent labs - BMP, CBC, Lytes, Culture Data\\
  * Record new imaging findings\\


Get sign out either right when you come in, or after you get numbers. You must get this before 6 am because this is when the night person leaves\\


===Rounds===
  * Chief/senior resident will text team night before regarding start time and will text team morning of regarding where to meet
  * Rounds are usually casual, very brief SOAP presentation with updates, overnight events, pertinent results, plans/to-do's for the day 
  * Bring appropriate wound care supplies on rounds - RECOMMEND gathering basic supplies in your bag (kerlix, 4x4 boats, xeroform, bacitracin packets, shears, ACE wrap, tape, wound vac dressing)
  * Dressing changes will be done in the mornings unless otherwise stated. RECOMMEND taking pictures of the wound in Haiku and on your phone. Send photos to senior resident
  * Run the list after rounds

===After rounds===
  * Place orders and call consults first. Then replenish electrolytes as needed.
  * Call Case Management at x34075 for phone rounds. Case manager usually answers their phone after 8:30AM.
  * Write daily progress notes for all patients that were rounded on
  * REMEMBER to see patients with free flaps at least twice per day and perform a flap check when they are within the 48 hour window post-op - write a flap check note after each flap check
  * REMEMBER if you are assigned to a first-start case, prioritize preparing for the case: place pre-operative orders, consent and mark the patient, place discharge or post-operative orders, electronically sign prescriptions or have attending/PA sign prescriptions
  * Most attendings at the University have a dedicated PA who will often assist with pre-op orders, consents and scripts. Double check these are complete before starting floor work

===After OR===
  * After the case do post-op orders - pain meds, antibiotics, bowel regimen, nausea prophylaxis, DVT prophylaxis, wound care orders, weight bearing status, morning labs, inpatient consults. 
  * Pro-tip - complete discharge orders for outpatient surgeries prior to starting case
  * Send outpatient prescriptions to AOP Pharmacy
  * Complete a brief op note - look in PACU discharge or Post-Op admit tabs
  * If the patient is a breast reconstruction with DIEP flap, refer to the DIEP protocol on the Wiki Page. This has day to day orders and milestones for patients
  * If in doubt regarding any orders, please check with the senior resident/attending to clarify
  * Add appropriate discharge instructions if outpatient surgery. Each attending has specific smart phrases for various common surgeries they perform. Steal their smart phrases accordingly. Can also ask senior residents for their smart phrases.
  * Complete unfinished floor work in between cases. This service can be busy so figure out the workflow that works best for you


===Consults===
  * If you get a consult you should let the consult resident know immediately and go and see the consult as soon as you can. The senior resident will either meet you at the consult or ask you to take pictures and send it to them
  * Take pictures of consults and show the pics to the fellow even if they are scrubbed in. Residents are always willing to help with consults even if they are scrubbed in
  * Occasionally, other services will consult you for intraoperative evaluation of wounds. If possible, leave your pager number in the OR that the consult will take place in. Be ready to take pictures of the wound and send the pictures to the senior resident
  

===Discharges===
  * Ensure patient has appropriate prescriptions and wound care orders prior to discharge. This includes home health if required for wound vac changes or dressing changes.
  * For specific orders, check with the Wiki page first for various types of cases. If you have additional questions, ask your senior resident about discharge orders (i.e. antibiotics, pain medications, muscle relaxants, DVT prophylaxis, aspirin etc.)
  * Pro Tip: you are able to electronically sign for narcotics prescribed to the university by changing the provider for medications to yourself. Ask a senior resident or another intern to show you how to do this
  * Add appropriate discharge instructions to the patient's After Visit Summary
  * Verify the patient has a follow-up appointment with their surgeon. If they do not have an appointment in their future encounters, message the plastic surgery clinic scheduler - send message to "P SP AMC Plastic Surg" and "P Plastic Surg Nurse/MA." Include patient's MRN, the surgeon/PA's name, and the approximate date of follow up
  * As a default, most patients will have follow up in plastic surgery clinic within 7 days of discharge
  * Clinic number is 720-848-0800. Hand Clinic is 720-848-0485. Nurse Line is 720-848-0007
  * Create a discharge summary for each discharge - this needs to be completed and signed within 24 hours of discharge

===End of day===
  * Update the handoff throughout the day based on new information or changes throughout the day. Include plans for the following day/week if applicable (e.g. change wound vac tomorrow)\\
  * Run the list with the senior resident at least once prior to the end of the day. You are encouraged to run the list even while they are scrubbed in a case
  * Tell night person a brief one liner and what you guys are doing for them. Assume they do not know the person because they carry 6-9 pagers on any given night.\\
  * If a patient is being operated on during sign out, make sure to sign-out to the night intern to perform a postop check after the patient leaves PACU\\
  * Let them know which resident is on call for that night and if they will be on hand call. Put their names, pager and cell phone numbers at the top of the list. The resident on call is listed on the wiki front page in the calendar\\

===Weekend===
  * You will often round on the day you are cross-covering other general surgery services. You are responsible for rounding on plastic surgery patients, writing notes, updating orders and plans, and performing routine floor work. In addition you will get signout about other services' patients and carry the pager until 6PM
  * On weekends you are not assigned to cross-cover, coordinate with your senior resident regarding which weekend day you will round. After completing all floor work, you can sign out the pager to the cross cover resident

===Tips and Tricks===
  * Refer to the wiki for [[medical_student:diep_post-op_protocol|DIEP flap protocols]]. There is a specific sequence of orders and milestones for each post operative day that is to be followed
  * Do not hesitate to ask the senior residents for help. This is especially so when you have a question about a flap during a flap check. If you notice any changes to the flap it is better to report it to the senior resident and ask if it needs to be addressed. Flaps are tenuous reconstructions that require attention and interventions are sometimes necessary
  * Steal all the smartphrases! They are your best friend\\
  * ALWAYS put in specific wound care orders if needed, either in a nursing communication or in a wound care order. Be very specific it won't be done right.
  * Refer to the wiki first for any questions. It has many resources including operative reports for different attendings' preferences for different surgeries\\


Numbers – (or 84845# universal code)\\
Sixth floor nutrition room: 6060#\\
Ninth floor supply room: 9191#\\
Tenth floor supply room: 0180 (of note, the master code doesn't work on this door)\\

Teaching Topics for Students -- Flap checks, wound vac principles and how to change them, deep dermal and running subQ sutures (these are what you will do mostly in the OR).\\